The final two sessions brought the workshop full circle to the role of evidence-based interventions in preventing suicide among people with serious mental illness. In the first of these sessions, four presenters with direct counseling and treatment experience described the approaches they and their organizations take toward individuals with suicidality, including those with serious mental illness. Several of the presenters had their own personal experiences with suicide, which have served as a guide and inspiration for them in developing relationships with their clients.
MULTIPLE INTERVENTIONS IN A DEPARTMENT OF VETERANS AFFAIRS SYSTEM
Nikole Jones, a suicide prevention coordinator with the Department of Veterans Affairs (VA) Maryland Health Care System, was working in a mental health care unit of the VA system in 2006 when a family tragedy changed the focus of her career. She said that she felt “skilled, trained, and confident about assessing for suicide risk,” but she did not know that a close family member was struggling in silence. When that family member died by suicide, she decided to become a suicide prevention coordinator, “because I realized that, as a provider-clinician, if I didn’t see those signs and symptoms in someone I cared about, I knew it would be impossible for veterans to see it in their peers and for their family members to see it in them.”
According to the research, only six veterans who die by suicide per day on average are receiving care through the VA system—of those, only two had received mental health care, Jones pointed out. The system does a good job of assessing veterans at risk of suicide who are receiving mental health care, but it has much less success reaching those outside mental health. Improving suicide screens in primary care and other areas of the hospital can improve identification of risk and access to needed resources, Jones said.
Once someone is identified as having an elevated risk for suicide, the VA system can call on a variety of effective interventions. It makes telephone calls, writes caring letters, and distributes free gun locks for lethal
means reduction. The VA system reaches out to churches, community mental health centers, community substance abuse programs, and other organizations to “make sure that the providers working with veterans in the community know the risk that veterans have and the resources that we offer at the VA.” The Veterans Crisis Line provides local responders who can determine whether there is imminent risk and, if not, make provider consults.1 The VA also reaches out to families, such as by letting them know that the Veterans Crisis Line is for family members as well as veterans. “Sometimes the veteran who’s at risk may not be willing to get help, or not ready to get help.” Outreach workers talk with family members about lethal means restriction, safety planning, and resources that are available.
The VA system has adopted the model #BeThere, which encourages everyone to rally behind our veterans that need support, said Jones. It tries to find out what gives veterans purpose so it can build on their interests and enthusiasm. “For our veterans, we want them to be able to be here tomorrow because their lives are valuable.”
BUILDING TRUST THROUGH ADVOCACY AND SERVICES
Alfreda Patterson is a substance use counselor and housing coordinator with Concerted Care Group (CCG) in Baltimore. It is an integrated program, which means “we meet the clients exactly where they are needed.” The program provides substance abuse, mental health, psychiatric rehabilitation, and many other kinds of services.
Patterson especially emphasized the group’s work on housing, since many of its clients are homeless. The group meets with clients to make sure they are eligible for one of its houses. It also connects them with a variety of support groups organized by CCG, such as groups centered on opioid treatment, mental health, trauma, and grief.
Patterson becomes an advocate for her clients. Whatever they need, she tries to get services for them or send them to other agencies that can meet those needs. CCG also uses a screening tool to identify the services that its clients need and connect them with those services. Again, housing is critical, said Patterson, because once clients are in housing they do much better in treatment. “They go to groups. They are getting jobs.” One of her clients was working with the Humane Society; another with a supermarket. “Our clients are engaged.”
Patterson said that 22 years ago she was in a situation comparable to those of some of her clients, but “when I needed those services, the services were not available.” But through medication-assisted treatment, she
1 The Veterans Crisis Line number is 1-(800)-273-TALK (8255).
was able to go to college, get a degree, and help other people like herself. Patterson said:
Sometimes [our clients] don’t think that I know what I’m talking about, or that a lot of us don’t know what we are talking about, because we are book people. But when they find out, “No, I’ve been exactly where you have been and I feel what you are feeling,” they get a sense that “Well, okay, I think I can trust her.”
This trust is “the number one key,” she said. “You try to get to know them. Therefore, they can get to know you and know that they can depend on you.”
OVERCOMING BARRIERS TO TREATMENT
T. J. Wocasek is clinical supervisor for the Southcentral Foundation in Anchorage, Alaska. He oversees the behavioral urgent response team, which is a 24/7 consultant-based team that provides three kinds of services. They address psychiatric emergencies and do risk assessments, for example, of patients who chose not to have a procedure for a life-threatening condition. They are medication providers for patients in the emergency room as well as for outpatients, such as people who have recently been released from the state psychiatric hospital. And they are health consultants who conduct screenings for substance use, depression, grief, and other conditions.
“This is a very meaningful topic to me,” said Wocasek. Thirty years ago one of his best friends and teammates died by suicide after school. Adults tried to tell him that it was an accident, but his friend was too smart to work on his car with the garage door down, Wocasek said. “Being truthful is very important, because I got very angry and bitter about the adults trying to protect my feelings rather than just saying what happened.” In the next year and a half, before he began college at the University of Arizona, four more of his friends attempted suicide and two died by suicide. “I’ve been on the other side,” he said. He used to think about suicide but asked himself what good he would be if he were dead. “That’s why I’m still here, because of that.”
He worked as a substance counselor with adults and adolescents and tried to help them get over what he called “thinking errors.” When he began working with the Southcentral Foundation, he encountered adolescents who were depressed, impulsive, and suicidal. They would try to avoid their treatment by playing pranks or getting in trouble. “I took that away right away,” he said. “I would say, you have two choices. You can either make decisions for your life, or you can have other people make decisions. Other people are judges, police officers, correctional officers, probation
officers, doctors, counselors. Which one do you want? I think 100 percent said they want to make their own decisions.” That is where treatment begins, he said.
Family values were another barrier to treatment. Coming to Anchorage meant that adolescents would have to adjust to a new culture, where nights are for sleeping and a healthy diet consists of salads and milk, not alcohol and Cheetos. His clients were still loyal to their parents, which created conflict. “I never judged them on that. It was just that here is another way to live your life and live longer.” They responded in particular to Native dancing and drumming, which “spoke to them,” he said.
Safety planning was emphasized, but Wocasek wanted people to be empowered to develop their own safety plans. He provided them with a template they could use to tell when they were in a crisis, how they could deal with a crisis, and how they would know a crisis is over. As an example of a helpful intervention, he described a system where he has people write on one side of an index card a problem they want to address. Then, on the back side of the card, they write down three to five ways to deal with that problem, whether drawing or listening to music or going for a walk. “You’re teaching them how to self-regulate. When they feel in that mood, or that issue comes up, they turn over [the card], they can pick any one, it’s their choice, they’re empowered to do that, and no one is controlling them.”
For some people, intensive case management is essential. Many people with mental health disorders have burned bridges with their families and support groups, so intensive case management is a way to keep an eye on them and not have them go to a hospital to seek help.
TAKING THE TIME TO PERSONALIZE TREATMENT
The day before the workshop, Keith Wood, clinical director of an intensive outpatient service focused on reducing psychotic symptoms through the teaching of positive life-functioning skills, was preparing to leave for the airport when a group of students came to him and said that they were treating a patient who met all the criteria for being suicidal. They needed a licensed clinician to put the person in the hospital. “It has to be quick,” he said, “because I have to catch a plane.”
The situation he encountered hit at almost every issue discussed at the workshop. With people who have serious mental disorders, a major issue is “do we have time to talk with people like this?” he said. “Do we get paid for doing that, and what is involved? . . . Is suicide really an issue?” The traditional guidance about whether someone may be suicidal does not necessarily fit for people with serious mental illness. Their illness may increase or decrease the likelihood of their being suicidal. If someone with
schizophrenia is told that their condition may increase the risk for suicide, they may say, “I don’t have schizophrenia. I don’t have a disorder.” If they accept the fact that they have schizophrenia or some other mental illness, that acceptance may increase the likelihood of their becoming suicidal, Wood said.
The state where Wood works has involuntary commitment procedures, which require filling out forms and getting security involved to put a person in handcuffs and take that person to a hospital. With the patient Wood saw the day before the workshop, other clinicians had joined them in the room, so they could have taken over that process. But, Wood asked, what happens when someone is hospitalized, even if just for a short time? They start losing their power of control. In contrast, the work he does with patients is designed to help them achieve more control over their environment. Thus, making a person a patient could again increase the risk of suicide. “If you take away their power, you take away their hope, you take away their control.”
Working with such patients takes time to develop a relationship and express concern, Wood pointed out. It takes time to explain that suicidal thoughts are not abnormal. Much of the work with patients who are thinking about suicide is crisis oriented—how do I protect that person, and how do I protect myself if that person does attempt suicide? “The more we make these individuals feel like they are they and not us, the more we stigmatize them, the more we make them estranged from ourselves, the less we are able to connect with them.”
Instead, such patients need to be empowered so they are part of the decision-making process, Wood said. That takes times, and people need to be paid for that time. It requires pulling in family members, community resources, and other providers. It requires developing safety plans and following up with patients to make sure that they adhere to that plan.
Wood did not end up hospitalizing his patient, and he and his colleagues are working with the patient on a safety plan. But this situation exemplified for Wood the challenges of doing prevention with a population that has been seen largely as passive recipients of care. “The way we manage them may have a lot to do with the outcomes that we’ve been seeing.”
GAPS IN AVAILABLE RESEARCH
The moderator of the panel, Andrey Ostrovsky, chief executive officer of CCG, asked the panelists whether enough research has been done on the populations they serve, or whether existing research can be adapted to those populations.
Wood said that he hoped the workshop would cause more research to be directed toward populations like the ones he serves. The people he serves
are often explicitly excluded from research—people with multiple diagnoses, people with little education or resources, and people who are homeless. For example, the most dangerous form of suicide involves firearms, but that is not the primary way that people with schizophrenia attempt to take their own lives. People with serious mental illness are “a significant proportion of the people who kill themselves but are not represented in the literature hardly at all.” These populations need much more research, he said, such as on ways of infusing prevention into the treatment process.
Jones agreed with that assessment and added that research needs “to talk the same language so we can compare across different groups.” For example, younger veterans have different reasons for attempting suicide than do older veterans. Also, predicting who is at risk from suicide is far from perfect. “One person may have a list of risk factors, and it would be too much, and someone else may have a list of protective factors, and it may not be enough.” Trying to draw lines around those who are at risk of suicide could miss others who are being drawn to suicide as well, she said.
Wocasek cited a slightly different problem with research on Native populations. Though his colleague Jennifer Shaw (see Chapter 5) conducts research on the work done by the Southcentral Foundation, that research needs to be approved by the institutional review board, and in some cases the board has not approved research involving Alaska Natives because of past abuses involving research.
BILLING FOR SERVICES
Ostrovsky also asked whether any of the panelists had experience with payment mechanisms aligned with the care that needs to be delivered rather than deriving from simple reimbursement codes. Jones responded by saying that the VA is committed to providing suicide prevention care:
That’s our whole role. . . . I’m not going to say, “Well, your hour is up, you have to go, I have someone waiting.” They know that we’re here for them in that crisis, and I think from their perspective that helps them trust the process and be open about their risk for suicide.
Not rushing the patients and providing enhanced care, as her center does, “makes veterans feel like everyone is working as a team to support them.”
Wood responded that he was “jealous of the VA system” and acknowledged that many valuable innovations have emerged from VA systems. “Part of it is because they’ve been under a more flexible payment system,” he said. “There are places in Georgia where we have moved more toward fee for service, which is lethal.” If someone is suicidal, the health care
system needs to be in contact with that person, said Wood. But a provider calling someone cannot get paid for that call, or a case manager may do something for someone that cannot be reimbursed. Other systems pay for these kinds of activities, and these systems tend to be less institutionalized, less mechanized, and more patient oriented. When systems have more flexibility and people can work more as a team, peers, family members, and other members of a community can be more readily involved in care. “There are systems that do a much better job at that in different points in the country, and we see some of that reflected in suicide rates but also in terms of people adapting to the community and life.”
From her perspective as a counselor in CCG, Patterson observed that funding services is less of a factor in her job than in comparable jobs elsewhere. “We have to get paid, but it’s all about the clients.” If a client needs to be a member of more than one group, the counselors make that happen, regardless of financing. As the chief executive officer of CCG, Ostrovsky contrasted that situation with payment mechanisms in Maryland, which until recently were heavily oriented toward fee for service. If, instead, a lump sum payment could be made for a patient’s care, while not the holy grail, providers could work together to do the right thing for people who need care. These alternative mechanisms should be tested, he said, and these tests should be conducted in diverse populations to see how the results of funding mechanisms vary from one group to another.
Finally, in response to a question about what they would change if they could change just one thing, Wocasek said that enhancing safety and privacy in the psychiatric unit of the emergency room would be his priority. The lack of privacy “is not fair to that patient that other people could potentially be hearing their history and their story.” Then he added a second wish: that intensive case management could keep an eye on people in the community and help them get the care they need.
Jones said that she would reduce the stigma surrounding suicide, “and I’ve been through it personally so I know.” When she works at suicide information tables at veterans events, people “see suicide and they just walk on by.” If people could talk openly and honestly about suicide, much more progress could be made. One thing she often hears from veterans is that whenever they mention suicide, the automatic response of the health care system is to escort them to the emergency department. If health care providers could respond instead by saying that having the thoughts is one thing and thinking about suicidal behaviors is another, that these thoughts come and go but you can control them, discussions about suicide could be much more open.
Patterson had a similar response, saying that she would like much more transparency in discussions of suicide, both among clients and among providers. “But for them to be transparent, they have to trust me. Every day I say let me see how I can be transparent to them so they can trust me and that way if they trust me I’m able to help them and they’re able to receive my help.” Finally, Wood said he would shift the emphasis within suicide prevention from pathology to adaptive functioning.
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